NDIA Accountability Project

Submission 3 — Jesuit Social Services — NDIA Support Coordination Discussion Paper

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Submission to the NDIS Support Coordination Discussion Paper Consultation

September 2020

Summary

Jesuit Social Services welcomes the opportunity to contribute to the National Disability Insurance Agency’s (NDIA) external consultation on its National Disability Insurance Scheme (NDIS) Support Coordination Discussion Paper (August 2020).

We recognise the complexity of needs experienced by people with disability, the challenges of providing and coordinating services in a way that meets each person’s individual needs, and the individual and broader economic benefits of providing effective support coordination to NDIS participants.

In this submission, we provide a brief overview of Jesuit Social Services’ work before responding to the targeted questions outlined in the NDIS Support Coordination Discussion Paper.

Jesuit Social Services is a registered NDIS service provider and we are in the process of becoming accredited with the NDIS, although we are not currently providing specific NDIS services.

We work with a small, but highly complex, cohort of people with mild/moderate intellectual or cognitive disability and other complex needs who often require long-term support to navigate the relevant service systems. Our submission draws on our experience working with participants who are often eligible to receive a combination of federal and state government financial support packages, including NDIS, and whose involvement in the justice and broader service systems is associated with significant disruption and discontinuity in their service provision.

Jesuit Social Services highlights that the existing NDIS fixed pricing structure does not accommodate the specialist and highly qualified and skilled workforce required to effectively support the cohort of people that we work with. Further, our organisation can only make financially viable the provision of NDIS services to this cohort in combination with additional support funding and the provision of NDIS support coordination. We outline how conflicts of interest can be effectively overcome in this context.

Jesuit Social Services notes a pattern of unilateral decision-making by the NDIA in relation to the NDIS, with limited or no consultation with service providers, and subsequent announcement of significant changes to pricing structures with very tight implementation timelines, despite significant impacts on the financial viability of service providers. We emphasise the need for the NDIA to engage in ongoing consultation processes and fine-tuning of policy and funding decisions in relation to the NDIS, and to provide adequate lead times for NDIS service providers to adjust their service offerings following any changes in these areas.

We look forward to further engagement with the NDIA in regard to these matters.

For further information about this submission, please contact:

Julie Edwards
CEO, Jesuit Social Services

email: Julie.Edwards@jss.org.au
BH: 9421 7604

Contents

Introduction

Jesuit Social Services welcomes the opportunity to contribute to the National Disability Insurance Agency’s (NDIA) external consultation on its National Disability Insurance Scheme (NDIS) Support Coordination Discussion Paper (August 2020).

We recognise the complexity of needs experienced by people with disability and other complex needs, the challenges of providing and coordinating services in a way that meets each person’s individual needs, and the individual and broader economic benefits of providing effective support coordination to NDIS participants.

Jesuit Social Services is a registered NDIS service provider and we are in the process of becoming accredited with the NDIS, although we are not currently providing specific NDIS services.

We work with a small, but highly complex, cohort of people with mild/moderate intellectual or cognitive disability and other complex needs who often require long-term support to navigate the relevant service systems.

Jesuit Social Services: Who we are and what we do

Jesuit Social Services is a social change organisation.¹ Our mission is to build a just society where all people can live to their full potential. For over 40 years, we have been working in solidarity with people and communities experiencing disadvantage and marginalisation.

We work where the need is greatest and where we have the capacity, experience and skills to make the most difference. We operate in multiple locations across Victoria, New South Wales and the Northern Territory.

Our service delivery and advocacy focus on the following key areas:

  • Justice and crime prevention — people involved with the justice system or at risk of becoming so involved.
  • Mental health and wellbeing — people with complex and multiple needs, including mental illness, trauma, homelessness and complex bereavement.
  • Settlement and community building — recently arrived immigrants and refugees, and disadvantaged communities.
  • Education, training and employment — people with barriers to sustainable employment.
  • Gender and culture — providing leadership on the reduction of violence and other harmful behaviours prevalent among boys and men; and building new approaches to improve their wellbeing and keep families and communities safe.
  • Ecological justice — inviting discussion on what practices, policies and actions can be taken by governments, individuals, organisations and the community services sector within Australia to build an ecologically just society. The pursuit of ecological justice underpins all that we do in our programs and advocacy.

¹ Jesuit Social Services website: https://jss.org.au/about-us/.

Jesuit Social Services’ advocacy and policy work are coordinated across all our programs and major interest areas. Our advocacy is grounded in the knowledge, expertise and experiences of our program staff and participants, as well as academic research and evidence.

We seek to influence policies, practices, legislation and budget investment, as well as community members themselves, to positively influence people’s lives and improve approaches to addressing long-term social challenges. We do this by working collaboratively with the community to build coalitions and alliances around key issues, and by building strong relationships with business and government.

Responses to the Questions in the NDIS Support Coordination Discussion Paper

Inclusion of support coordination in plans

  1. What factors should be considered when determining if, when and for how long support coordination should be funded in an NDIS participant’s plan?

Jesuit Social Services recognises that participants’ needs vary in terms of type and level of disability. In our experience, some people with multiple and complex needs — especially including intellectual disability (ID) — may require long-term support from Support Coordinators. The individual needs of this cohort must be carefully considered, in line with assessment reports and recommendations from the various mental health and psychology practitioners, occupational therapists, etc., who are involved with a participant.

It is crucial that support coordination not be removed from a participant’s NDIS plan where objectives identified in previous plans are not met. On the contrary, lack of achievement of sought after outcomes may well be an indicator that the participant requires additional and ongoing support coordination.

  1. Should the current three level structure of support coordination be retained or changed?

Jesuit Social Services holds that the current three-level structure of support coordination should be retained. This structure provides a pathway for professional development and, as workers become more skilled, they will be enabled to work with different participant cohorts and provide higher level support. Sector development, including specialist skills development of individual workers, is vital to ensure an adequate supply of appropriately qualified and experienced workers to be able to support the complex and specific needs of the cohort that Jesuit Social Services works with.

In particular, Jesuit Social Services strongly supports retention of Level 3 support coordination, because of the level of expertise required to work effectively with the cohort of participants with complex and multiple needs. We anticipate that there would be a significant negative financial impact on service providers working with this cohort should Level 3 support coordination be terminated. We have undertaken cost-benefit analyses in relation to rates of funding and would be willing to discuss this work further with the NDIA, if requested.

We note that the number of hours of support coordination funded in NDIS plans is generally not commensurate with the range and complexity of participants’ needs and the hours required to coordinate all their support services, given the specific focus on the participant’s disability.

Notwithstanding, the rate for Level 3 support coordination recognises that this work is complex. In contrast, the Victorian Government’s Multiple and Complex Needs Initiative (MACNI) packages for specialist services for people with multiple and complex needs does recognise the greater support coordination needs of this cohort in the number of hours funded.

  1. How should support coordination interact with other NDIS supports? For example, local area coordinators, community connectors, liaison officers and recovery coaches?

Clear parameters are required for all NDIS management and coordination roles. Jesuit Social Services considers that, currently, there is too much similarity between roles and overlapping of functions. This contributes to a lack of ownership of responsibility for ensuring necessary support requirements and exacerbates deficits in service delivery.

A strong coordination function is necessary to ensure that individual participant’s support needs do not fall between the gaps in service provision. It is Jesuit Social Services’ view that this would be facilitated through provision by the NDIA of clear role and function definitions that are easy for both participants and service providers to understand and access.

  1. How should support coordination interact with and complement existing mainstream services?

Jesuit Social Services’ Way of Working (see Appendix A) provides a holistic response to participants’ needs and we recommend that NDIS and mainstream services also adopt this holistic approach. In this context, mainstream services must be made aware of and educated regarding the role and function of Support Coordinators. The provision of clear and targeted information for mainstream services regarding the NDIS and Support Coordinators is thus recommended. Support Coordinators should be maximising the use of mainstream services, complementing the services available through NDIS. Continuity of service and support is imperative for a participant to achieve personal outcomes, and mainstream services should be facilitating this. It is unhelpful for participants who spend periods in custody, for example, to have their NDIS plan stop each time they enter custody and re-start each time they exit custody.

  1. What can or should be done to address the level of utilisation of support coordination in plans; and is this any different to general issues of utilisation?

There needs to be an understanding of the reasons for under-utilisation of support coordination in many NDIS plans and, in some cases, no use of support coordination at all. For example, do participants and/or service providers understand support coordination and what it can assist them with? Is support coordination being removed from subsequent plans if under-utilised in an initial plan? Are there enough skilled support coordinators with appropriate sector knowledge to be able to provide this service to participants?

Jesuit Social Services considers that a lack of service providers for participants with complex needs means Support Coordinators cannot provide a full service, leading to support coordination being cut in subsequent plans as it is erroneously deemed to be unnecessary or under-utilised.

We consider that there is also a lack of experienced and knowledgeable Support Coordinators in the sector due to the NDIS still being in its early stages and low hourly rates for the support

coordination role. Some support Coordinators do not have the necessary skills and experience across the range of support domains required to provide a comprehensive plan for participants — this includes a detailed understanding of the criminal justice, homelessness/housing, mental health, and drug and alcohol service systems.

Role of support coordination

  1. What functions should a support coordinator perform? Are there tasks that a support coordinator should not do?

There is a need to clearly define support coordination and similar roles to achieve the best possible participant outcomes — as indicated in our response to Question 3 above, and demonstrated in the case study provided in Appendix B. The aim should be to ensure simple definitions of streamlined roles that do not duplicate functions.

NDIS Support Coordinators must be authorised and encouraged to advocate for participants to access specific services, with particular attention paid to those with complex and multiple needs. Many participants do not have family support and, even where they do, it is often beyond the capability of non-professionals to access the services required by a participant.

With appropriate and transparent conflict of interest policies and management processes in place, service providers should be able to effectively provide support coordination and simultaneously deliver relevant services.

  1. Is there evidence that participants with specific plan goals related to education, accommodation and employment would benefit from more targeted support coordination services to achieve these outcomes?

Jesuit Social Services considers that participants would benefit from the contributions of Support Coordinators with specific skill sets in the areas of education, housing, employment, and the criminal justice, mental health, and drug and alcohol service systems. We believe such targeted support would lead to better outcomes for the participant. We also acknowledge that expertise in working with people with intellectual and/or mental health disability requires a specialised approach, compared with working with people with a physical disability.

  1. How could plan management and support coordination be more closely aligned and what would the potential benefits and risks be?

Jesuit Social Services makes no comment in response to this question.

Quality of support coordination

  1. Should there be minimum qualification requirements or industry accreditation in place for support coordinators? If so, what might be applicable?

Jesuit Social Services considers that Support Coordinators should be required to have a minimum qualification, sector experience and industry accreditation linked with the level of support provided. There needs to be a higher hourly rate paid for Level 1 support coordination (the lowest level) and access to appropriate professional development to enable Support Coordinators to

move through the higher levels and build up this capacity within the sector. Jesuit Social Services recommends that there be specific minimum qualifications and experience required for Level 3 support coordination that is higher than for Levels 1 and 2.

Jesuit Social Services recognise the importance of quality supervision, reflective practice and ongoing professional development, and these are vital aspects of Our Way of Working.

  1. How can the effectiveness of support coordination be measured and demonstrated?

    It is not appropriate to measure the effectiveness of support coordination solely on the basis of outcomes, particularly for the complex cohort that Jesuit Social Services works with. Capacity to achieve outcomes can shift over time and not be met in the first effort. However, after several attempts and with the right support over a sustained period, success is attainable. Similarly, it is not appropriate to measure the effectiveness of support coordination solely through participant satisfaction with the scheme, as this is not based on support coordination alone.

    Jesuit Social Services considers it important to combine such measures — by gathering feedback from participants in relation to their experiences, as well as the experience of mainstream services and other service providers, in relation to implementation of the participant’s plan and their broader intersection with crisis responses (i.e. custody, hospitalisation).

    Relatedly, where support coordination has been under-utilised, it is important to explore the need to continue support coordination in subsequent plans, including gaining an understanding of the reason for the under-utilisation of support coordination. Our experience is that NDIS Support Coordination hours are insufficient to meet the needs of participants with multiple and complex needs.

  2. Are there emerging examples of good practice and innovation in support coordination?

    Jesuit Social Services advocates Our Way of Working as a model of good practice in working with participants to reach their full potential. Please refer to Appendix A for an overview of our practice model.

  3. Are the levels and relativities in the NDIA price limits across different services including support coordination working effectively in the interests of participants and a sustainable, innovative market?

    Jesuit Social Services considers that the Level 1 hourly rate is too low and, presumably, that few services are seeking to provide such support coordination. Further, there appears to be insufficient differentiation between Levels 2 and 3, and those who should really only be providing Level 1 support coordination are perhaps overcharging for a lesser support coordination service.

  4. Should support coordination pricing be determined, at least in part, based on progression of participant goals and outcomes, and how might this work?

    Jesuit Social Services considers — in line with our responses to Questions 1, 5 and 10 above — that support coordination pricing should not be based on progression of participant goals and outcomes. This cohort, in particular, may not achieve a goal or outcome for a range of reasons

and removing support coordination from a participant’s plan or lowering the hourly rate for this function would be a counter-productive response.

Building capacity for decision making

  1. How can a support coordinator assist a participant to make informed decisions and choices about their disability supports? What are the challenges?

    It is necessary to assess the capacity of the participant and their existing supports and advocacy on an individual basis, given those with very complex needs may need more assistance and support in making informed decisions than others. Irrespective of the participant’s capacity, an appropriately skilled and experienced Support Coordinator can work alongside a participant to support them to make informed decisions.

  2. How does a support coordinator build a participant’s independence rather than reliance? Should support coordination pricing be determined, at least in part, based on building a participant’s capacity for decision making to become more independent?

    Jesuit Social Services always works with participants to build their capacity as much as possible. Guided by Our Way of Working, we also recognise the importance of striking a balance, given independent decision-making is not always a realistic goal in the NDIS context. Support coordination should not be priced solely on the basis of building a participant’s capacity for decision-making and independence because some people’s disability means they require long-term support in decision-making.

  3. How can a support coordinator assist a participant in need of advocacy without acting outside the parameters of their role? What are the appropriate parameters of the personal advocacy role and the support coordination role?

    Jesuit Social Services considers that advocating for a participant should fall within the remit of a Support Coordinator’s role when endeavouring to source appropriate services, depending upon who is involved in supporting the participant, with a view to streamlining the number of players involved in implementing the participant’s NDIS plan.

    We reiterate, as stated in our response to Question 6 above, that not all participants (or their families, where applicable) have the skill set to be able to advocate effectively on their own behalf. For participants in disenfranchised cohorts, Support Coordinators could, and arguably should, play a vital role in advocating for access to needed services on behalf of the participant.

Conflict of interest

  1. In what circumstances is it more or less appropriate for a participant to receive multiple supports from a single provider?

    Participants with complex needs may find it helpful to simplify their supports where there are numerous services involved. The more a Support Coordinator can do (with adequate protections in place), the better for the participant in receiving a more holistic response. Furthermore, it is better for a consistent support person to remain engaged, as they can focus on building the relationship with the participant. Too many supports can be confusing and overwhelming for a

participant and can lead to disjointed and impersonal service responses. This is the antithesis of the person-centred, relational approach used by Jesuit Social Services, which we find effective with the cohorts we work with.

It can be appropriate for a participant to receive multiple supports from a single provider when there is a limited/thin market of service providers catering to specialist and complex needs of participants, particularly if conflicts of interest are well understood and explained, appropriately documented and effectively managed. The effective management of potential, real or perceived conflicts of interest requires an organisation to have good governance, transparency and accountability structures and processes in place.

  1. Should the IAC recommendation for the NDIA to enforce an “independence requirement between intermediary and other funded supports at the participant level” be adopted?

    Jesuit Social Services requires more information regarding what “independence requirements at the participant level” would look like to be able to respond comprehensively to this question. For example, does it mean improving transparency and regulation for managing conflicts of interest on the part of providers? Or does it mean that providers would not be able to provide support coordination, as well as other NDIS support? It is strongly our position that with the appropriate governance structures in place we can manage independence and autonomy of functions.

  2. What impacts would stricter conflict of interest requirements have on NDIS participants and the NDIS market?

    Jesuit Social Services notes, again, that this would depend on the type of restrictions that were applied. Potentially, for example, there would be a reduction in choice for participants if organisations were not permitted to provide both support coordination and other NDIS services.

    Jesuit Social Services emphasises that we endeavour to always act in the best interests of NDIS participants by ensuring that participants are informed, empowered and able to maximise choice and control.

    We understand the potential for conflicts of interest to occur, particularly in the context of providing multiple NDIS services, including support coordination. Jesuit Social Services has approved policies and documented procedures in place for managing actual, potential and perceived conflicts of interest at governance, operational, worker and participant levels in the delivery of support coordination in conjunction with other NDIS supports. This includes separation of functions, different line management reporting, and data and participant records being held discreetly from other programs. We believe that with the appropriate governance structures in place, the risk of a conflict of interest disadvantaging a participant can be effectively overcome.

    Jesuit Social Services believes it is often not practical or appropriate for support coordination to be split from other NDIS funded services due to the unique, specialised and complex needs of the participant cohort we work with. Not permitting an organisation to be a support coordination provider, as well as a service provider, means there is a genuine reduction in choice for participants to engage a quality service provider. There are occasions where a participant will choose to purchase a range of services from Jesuit Social Services, in addition to support coordination, due to the limited availability of other specialist support options. It is not fair or

appropriate to restrict the choices of participants due to other service providers using support coordination inappropriately. There is also a strong risk that the number of direct service providers would decrease if the pricing of NDIS support coordination were to be reduced. Jesuit Social Services, for example, cannot afford to provide NDIS services without the inclusion of support coordination, especially without Level 3 support coordination, which is essential for the cohort we work with. (As mentioned in our comments for Question 2, Jesuit Social Services has undertaken cost-benefit analyses in relation to rates of funding, which we would be willing to discuss with the NDIA, if requested.)

An important aspect of support coordination is supporting people to make decisions about the risks they take in their lives. An NDIS plan that is executed without taking informed, transparent and proportional risks is a missed opportunity for everyone. Those risks may include choosing services that have a real or perceived conflict of interest where these can be managed effectively.

General

  1. What would you identify now as the current critical issues around support coordination?

    Jesuits Social Services identifies a range of current critical issues in relation to support coordination. These include:

    • lack of role clarity, consistency, and qualifications and professional standards;
    • under-utilisation of support coordination because the function is misunderstood;
    • not enough service providers able to undertake this function at the Level 3 end because of the degree of specialist skills required, and at Level 1 because of inadequate hourly rates;
    • conflict of interest issues preventing some service providers from contributing to support coordination; and, consequently,
    • piecemeal and sub-optimal service provision for participants, particularly those who have multiple and complex needs.

  2. What are the priority actions the NDIA might take to grow an innovative and effective support coordination market in the interests of participants?

    Our response to this question follows from our comments in response to Question 20 above and summarises our suggestions in relation to the other questions addressed in this submission.

    Jesuit Social Services suggests that the following priority actions be taken by the NDIA to strengthen support coordination provision with a view to improving outcomes for NDIS participants:

    • increase pricing for support coordination, especially Level 1;
    • recognise the need for highly skilled workers and provide appropriate professional development;
    • recognise that support coordination will be required for some participants long-term, particularly those with complex and multiple needs;
    • simplify and clarify the lines of responsibility and accountability;
  • allow Support Coordinators to take on more responsibilities so as to provide a more holistic response to participants; and
  • allow organisations to provide support coordination and service provision, where they have appropriate conflict of interest mechanisms in place.

Appendix A: Our Way of Working

Our Way of Working, underpins all Jesuit Social Services doing and influencing work with individuals and communities. The framework speaks to the inherent humanity of each individual every community, and their capacity to envisage and achieve a more positive and engaged future, no matter their current circumstances. It articulates the dynamic interplay of five components, which work together to help people reach their full potential and become active participants in their communities.

The five domains in the Our Way of Working framework

  • Valuing self and others: practising and encouraging respect so that that those with whom we work enhance their capacity to establish and maintain meaningful and respectful relationships in their personal lives and respect for the environment, recognising the interconnectedness of all life.
  • Affirming goals and aspirations: engendering hope through envisioning new futures and the establishment of supportive and reciprocal relationships. Accompanying people as they explore new ways of working collaboratively and sustainably.
  • Linking individuals and communities to relevant supports: assisting people to realise their potential to improve their mental, physical and emotional health, and to remove the barriers they face in achieving social and economic inclusion through access to services, supports and resources.
  • Using skills and building capacity: delivering education, training and therapeutic programs that develop living skills and improve pathways to further education and employment, and by working collaboratively with communities to build social cohesion and shared outcomes.
  • Enhancing civic participation where individuals and communities build communities of justice and exercise their right and responsibility to create a just, inclusive and sustainable world.

Building a just society is central to Our Way of Working. The fifth domain in the framework, enhancing civic participation, reflects our understanding that it is through relationships and participation that people are most fulfilled, are able to create shared futures, and become active players in advancing a just society: a society where the answers to environmental and social concerns are inextricably linked through ecological justice.

Appendix B: Case Study

Case study: Melissa²

Melissa is a 19-year-old woman who was referred to Jesuit Social Services by MACNI with a range of needs requiring specialist service support, including a history of trauma, mental health issues, drug and alcohol misuse (AOD), and involvement with the justice system. Melissa had a MACNI package overseen by a MACNI Coordinator, and an NDIS package which included 77 hours of Support Coordination for the year.

Due to the complexities of Melissa’s needs, a range of services were involved — these supports were not only varied, but also disjointed and inconsistent. Due to the nature of Melissa’s disability, both her MACNI and NDIS funding packages included supports relating to aspects of her disability, thus creating an unclear division of responsibilities. Whilst Melissa’s NDIS Support Coordinator attended Melissa’s care team meetings regularly, Melissa’s broader care team was large and had many workers supporting her, including all of Melissa’s non-disability related needs.

This complex setting created a range of issues relating to Melissa’s funded Support Coordination.

The number of hours funded for the NDIS Support Coordinator amounted to approximately 1.5 hours per week. A large portion of this was automatically used up due to the necessary frequency and regularity of the required care team meetings. This did not leave sufficient time for the NDIS Support Coordinator to undertake necessary activities relating to implementation of Melissa’s NDIS plan.

It also meant there were significant limitations on the NDIS Support Coordinator’s capacity to build essential relationships, not only with Melissa herself, but with other services involved in implementing Melissa’s plans.

The complexity of the response required to achieve positive outcomes for Melissa meant the NDIS Support Coordinator was not able to value-add to discussions regarding possible responses to Melissa’s disability-related needs due to limited scope, lack of capacity, and lack of understanding of the drug and alcohol issues, and forensic and past trauma factors impacting Melissa.

The unforeseen result of this was that the care team, and Melissa, constantly deferred to the MACNI Support Coordinator to lead the response relating to Melissa’s care, including her disability-related needs. The NDIS Support Coordinator could not engage actively in the care team’s discussions, nor could they play a proactive role in implementing Melissa’s NDIS plan.

Importantly, the coordination role was critical to the success of Melissa’s support, and the NDIS Support Coordination role should have been an essential component of that. However, the NDIS Support Coordinator’s very limited capacity, lack of sector specific knowledge and expertise, and absence of involvement with other services involved meant that Melissa did not reap the benefits of having Support Coordination in her NDIS plan. Rather, she deferred continuously to the MACNI Coordinator, who ultimately oversaw the care team and the implementation of Melissa’s plans, both MACNI and NDIS.

For the NDIS Support Coordination role to be more beneficial in cases like Melissa’s, there would need to be:

² For privacy reasons, ‘Melissa’ is a fictitious name and this case study represents a composite of several participants that Jesuit Social Services has worked with.

  • a significant increase in the number of NDIS Support Coordination hours allocated to participants with complex needs to enable not only attendance at care team meetings, but also relationship building with the participant and other service providers, and follow up actions to be actively pursued and implemented;
  • a higher level of knowledge and expertise of the relevant sectors in line with the NDIS participant’s needs, such as AOD and forensic;
  • clearly articulated roles and responsibilities of the NDIS Support Coordinator and the MACNI coordinator;
  • an integrated approach to service provision from NDIS and MACNI;
  • a clear and transparent legislative framework stipulating requirements for NDIS Support Coordinators, and to ensure accountability and transparency; and
  • increased understanding of the role of the NDIS Support Coordinator amongst mainstream, and other, services.